A modern day szasz?
This is a provocative but an engaging book that argues that the impact of ‘modern medicines’ in reducing the burden of mental illness, most particularly schizophrenia and other psychoses, has been exaggerated by advocates of biological psychiatry and the potential role of psychological therapies underutilised. Bentall states he is not a latter day Szasz and acknowledges the reality of psychoses and the role of antipsychotic medications in treatment. However, in a series of chapters, he brings together evidence of the weakness of current psychiatric nosology and flaws in biological research, notably the overestimation of heritability statistics to support his proposal of a model of mental illness that incorporates biologic, social and psychological determinants. The book is scholarly and well researched yet readable for the lay person. It would be of most interest to people with a lived experience of mental illness as well as to mental health clinicians.
There are a few quibbles. Psychiatrists may find parts disconcerting and have issues with statements such as, “Warmth, kindness and the instilling of hope… are intrinsic elements of psychotherapy but not of drug treatments” (p. 245). As a medical educator as well as psychiatrist, I would have to differ as empathy and rapport are essential in all clinical encounters where treatments are prescribed. The grouping of electroconvulsive therapy, which is an evidence-based treatment still in use with historic treatments, such as insulin coma (p. 36), is inappropriate. In addition, whilst a ‘biologic’ approach may be pre-eminent in practice by some or many in the United States and/or United Kingdom, this is not universal. The ‘biologic, social, psychological and (more recently) spiritual’ aetiological and treatment model of Engel (1989) is still widely used and expected in the formulation of a patient’s problems in trainee psychiatry examinations—at least in the Antipodes. There is selective reporting. The Kirsch study is cited as showing antidepressants do not work better than placebo (p. 210). However, that study did indicate that in moderate and even more so severe depression, antidepressants have an advantage over placebo. Contrary to the statement that no one is arguing that antidepressants prevent suicide (p. 212), there is evidence being debated that the rise in modern antidepressant use, particularly selective serotonin reuptake inhibitors, has been associated with lower rates of suicide (Baune and Hay 2006). These errors of fact diminish Bentall’s argument.
An appealing aspect of this book is the effort to place the content within an historic framework and to bring together the disparate histories of the major disciplines in mental health treatment: psychiatry and clinical psychology. The investigation of the parallel but intersecting journeys of these two major clinical professions helps us understand the differing points of practice that currently distinguish them. However, in the provocatively titled final chapter “What kind of psychiatry do you want?”, there is a Cartesian-like dualistic presentation of the non-empathic biological psychiatrist versus the empathic psychologist, or the ‘paternalistic-medical’ versus ‘autonomy-promoting’ mental health professional. In my view, this misses the point. There are times when a practitioner may act to rescue a patient from self and societal neglect (being thus paternalistic) and times when the same practitioner will, through focussed therapy, work with the same patient to promote decreased dependency and improved self-esteem. In the third volume of Frame’s autobiography (Frame 1985), we have a clear and true account of a woman struggling with mental illness. Her journey of recovery with clinicians was simultaneously ‘biological’ (“Infected by Dr Miller’s enthusiasm I performed and underwent tests of many kinds, mental, manual. I had an electroencephalogram…” p. 102) and ‘psychological’ (“…I did need professional help to free myself from the consequences of my long stay in hospital. I would remain in the Maudsley while my interviews with Dr Miller continued” p. 104).
A sceptical reader may thus remain unconvinced by Bentall’s thesis. However, there can be no debate with his central postulate that mental health professionals need to practice with humility and compassion. Psychiatric classification is indeed problematic (in too many ways to enumerate here!) and the major psychoses are more alike than present diagnostic schemes would imply. It could be argued that antipsychotic medications are no more a specific therapy than diuresis is in heart failure—they both work but do not explain why the heart (or brain) failed. There will be no single ‘gene’ found for even the most ‘biologic’ of mental health disorders as currently defined. Enthusiasm for new technologies has perhaps obscured the fact that, whilst brain changes occur in psychiatric illness, empirical understanding of putative organic aetiologies remains largely elusive. Critical thinkers like Bentall are welcome and are important for provoking argument, ensuring non-complacency, stimulating research and improving practice. In this respect, he is a “modern day Szasz.”